Factors affecting patients' journey with primary healthcare services during mental health-related sick leave.

CONTEXT: Best practice guidelines for the recovery and return to work (RTW) of people with mental disorders recommend access to the services of an interdisciplinary team combining pharmacological, psychological and work rehabilitation interventions. In the Canadian context, primary healthcare services are responsible for providing these services for people with common mental disorders, such as depressive or anxiety disorders. However, not everyone has easy access to these recommended primary healthcare services, and previous studies suggest that multiple personal, practice-related and organizational factors can influence the patient's journey. Moreover, previous studies documented that family physicians often work in silos and lack the knowledge and time needed to effectively manage by themselves patients' occupational health. Thus, the care and service trajectories of these patients are often suboptimal and can have important consequences on the person's recovery and RTW. OBJECTIVE AND POPULATION STUDIED: Our study aimed to gain a better understanding of the patient journeys and the factors influencing their access to and experience with primary healthcare services while they were on sick leave due to a common mental disorder. METHODS: A descriptive qualitative research design was used to understand and describe these factors. Conventional content analysis was used to analyze the verbatim. RESULTS: Five themes describe the main factors that influenced the patient's journey of the 14 participants of this study: (1) the fragmented interventions provided by family physicians; (2) patients' autonomy in managing their own care; (3) the attitude and case management provided by the insurer, (4) the employer's openness and understanding and (5) the match between the person's needs and their access to psychosocial and rehabilitation services. CONCLUSIONS: Our findings highlight important gaps in the collaborative practices surrounding the management of mental health-related sick leave, the coordination of primary healthcare services and the access to work rehabilitation services. Occupational therapists and other professionals can support family physicians in managing sick leaves, strengthen interprofessional and intersectoral collaboration and ensure that patients receive needed services in a timelier manner no matter their insurance coverage or financial needs. PATIENTS OF PUBLIC CONTRIBUTION: This study aimed at looking into the perspective of people who have lived or are currently experiencing a sick leave related to a mental health disorder to highlight the factors which they feel hindered their recovery and RTW. Additionally, two patient partners were involved in this study and are now engaged in the dissemination of the research results and the pursuit of our team research programme to improve services delivered to this population.

Clinical practice guideline recommendations to improve the mental health of adult trauma patients: protocol for a systematic review.

INTRODUCTION: Mental disorders are common in adult patients with traumatic injuries. To limit the burden of poor psychological well-being in this population, recognised authorities have issued recommendations through clinical practice guidelines (CPGs). However, the uptake of evidence-based recommendations to improve the mental health of trauma patients has been low until recently. This may be explained by the complexity of optimising mental health practices and interpretating CGPs scope and quality. Our aim is to systematically review CPG mental health recommendations in the context of trauma care and appraise their quality. METHODS AND ANALYSIS: We will identify CPG through a search strategy applied to Medline, Embase, CINAHL, PsycINFO and Web of Science databases, as well as guidelines repositories and websites of trauma associations. We will target CPGs on adult and acute trauma populations including at least one recommendation on any prevention, screening, assessment, intervention, patient and family engagement, referral or follow-up procedure related to mental health endorsed by recognised organisations in high-income countries. No language limitations will be applied, and we will limit the search to the last 15 years. Pairs of reviewers will independently screen titles, abstracts, full texts, and carry out data extraction and quality assessment of CPGs using the Appraisal of Guidelines Research and Evaluation (AGREE) II. We will synthesise the evidence on recommendations for CPGs rated as moderate or high quality using a matrix based on the Grading of Recommendations Assessment, Development and Evaluation quality of evidence, strength of recommendation, health and social determinants and whether recommendations were made using a population-based approach. ETHICS AND DISSEMINATION: Ethics approval is not required, as we will conduct secondary analysis of published data. The results will be disseminated in a peer-reviewed journal, at international and national scientific meetings. Accessible summary will be distributed to interested parties through professional, healthcare quality and persons with lived experience associations. PROSPERO REGISTRATION NUMBER: (ID454728).

Implementation model for a national learning health system (IMPLEMENT-National LHS): a concept analysis and systematic review protocol.

INTRODUCTION: Despite efforts and repeated calls to improve the organisation and quality of healthcare and services, and in view of the many challenges facing health systems, the results and capacity to adapt and integrate innovations and new knowledge remain suboptimal. Learning health systems (LHS) may be an effective model to accelerate the application of research for real quality improvement in healthcare. However, while recognising the enormous potential of LHS, the literature suggests the model remains more of an aspiration than a reality. METHODS AND ANALYSIS: To reach a fine understanding of the implementation of the concepts involved in LHS, we will use a hybrid method which combines concept analyses with systematic review methodology. We will use a two-step analysis, a content analysis to analyse the definitions, uses and attributes of the concept and a systematic review to analyse the concept's implementation mechanisms. We will search eight databases and grey literature and present a broad synthesis of the available evidence regarding design, implementation and evaluation of LHS in a multilevel perspective. We will follow the latest Preferred Reporting Items for Systematic Review and Meta-Analysis statement for conducting and reporting a systematic review. Two reviewers will independently screen the titles and abstracts against the eligibility criteria followed by full-text screening of potentially relevant articles for final inclusion decision. Conflicts will be resolved with a senior author. We will include published primary studies that use qualitative, quantitative or mixed methods. The assessment of risk of bias will be made using the Mixed-Methods Appraisal Tool. ETHICS AND DISSEMINATION: This systematic review is exempt from ethics approval. The results formulated will highlight evidence-based interventions that support the implementation of a national LHS. They will be of particular interest to decision makers, researchers, managers, clinicians and patients allowing finally to implement the promising proposal of LHSs at national scale. PROSPERO REGISTRATION NUMBER: CRD42023393565.

Understanding the impacts of the COVID-19 pandemic on the care experiences of people with mental-physical multimorbidity: protocol for a mixed methods study.

BACKGROUND: Primary care and other health services have been disrupted during the COVID-19 pandemic, yet the consequences of these service disruptions on patients' care experiences remain largely unstudied. People with mental-physical multimorbidity are vulnerable to the effects of the pandemic, and to sudden service disruptions. It is thus essential to better understand how their care experiences have been impacted by the current pandemic. This study aims to improve understanding of the care experiences of people with mental-physical multimorbidity during the pandemic and identify strategies to enhance these experiences. METHODS: We will conduct a mixed-methods study with multi-phase approach involving four distinct phases. Phase 1 will be a qualitative descriptive study in which we interview individuals with mental-physical multimorbidity and health professionals in order to explore the impacts of the pandemic on care experiences, as well as their perspectives on how care can be improved. The results of this phase will inform the design of study phases 2 and 3. Phase 2 will involve journey mapping exercises with a sub-group of participants with mental-physical multimorbidity to visually map out their care interactions and experiences over time and the critical moments that shaped their experiences. Phase 3 will involve an online, cross-sectional survey of care experiences administered to a larger group of people with mental disorders and/or chronic physical conditions. In phase 4, deliberative dialogues will be held with key partners to discuss and plan strategies for improving the delivery of care to people with mental-physical multimorbidity. Pre-dialogue workshops will enable us to synthesize an prepare the results from the previous three study phases. DISCUSSION: Our study results will generate much needed evidence of the positive and negative impacts of the COVID-19 pandemic on the care experiences of people with mental-physical multimorbidity and shed light on strategies that could improve care quality and experiences.

[Quality indicators of person-centred and recovery-oriented care for mental health issues]. / Indicateurs de qualité des soins en santé mentale pour les approches centrées sur la personne et axées sur le rétablissement.

Objective Meeting the mental health needs of the population is a priority of the Quebec government. To do so, it is important to evaluate and improve the quality of mental health care in primary and community care settings, particularly with respect to person-centred and recovery-oriented care. The purpose of this study is to identify existing quality indicators that measure these dimensions, and to report on their strengths and weaknesses. Method A review of systematic reviews was conducted in MEDLINE, EMBASE, PsycINFO and CINAHL, using combinations of search terms related to the concepts of "mental disorders," "primary care," "health care quality," and "review." The review of titles and abstracts review was completed by single reviewers and full-text review by pairs of reviewers working independently. Consultation with an expert in mental health care quality and a hand search of the references of identified articles finalized the search. A review of the grey literature, including the reports and websites of Canadian or international organizations, was also conducted. Results From 2837 initial references, the review of systematic reviews led to the inclusion of 6 systematic reviews. For the grey literature, relevant indicators were found on the websites of 13 organizations, including 7 international and 6 Canadian ones, from 25 organizations consulted. A total of 106 indicators were retrieved, including 91 for person-centred care approaches and 15 for recovery-oriented approaches. Among the indicators for person-centred care, two levels emerged: the organizational level, focusing mainly on continuity issues, and the practice level, focusing on processes related to the care providers or the individual. For recovery-oriented approaches to care, four categories emerged: community connections, discrimination and stigma, social roles, and social support. Conclusion Evaluating person-centered, recovery-oriented care for people with mental disorders based on robust quality indicators poses a major challenge and our review revealed several limitations related to the current set of indicators that exist to measure these approaches. Further efforts must be made to improve the measurement of quality of mental health care in terms of person-centred and recovery-oriented care, so that the governmental and clinical strategies currently in place, such as the Programme Québécois pour les Troubles Mentaux (PQPTM), can achieve their goals.

Personalized care planning and shared decision making in collaborative care programs for depression and anxiety disorders: A systematic review.

BACKGROUND: Collaborative care is an evidence-based approach to improving outcomes for common mental disorders in primary care. Efforts are underway to broadly implement the collaborative care model, yet the extent to which this model promotes person-centered mental health care has been little studied. The aim of this study was to describe practices related to two patient and family engagement strategies-personalized care planning and shared decision making-within collaborative care programs for depression and anxiety disorders in primary care. METHODS: We conducted an update of a 2012 Cochrane review, which involved searches in Cochrane CCDAN and CINAHL databases, complemented by additional database, trial registry, and cluster searches. We included programs evaluated in a clinical trials targeting adults or youth diagnosed with depressive or anxiety disorders, as well as sibling reports related to these trials. Pairs of reviewers working independently selected the studies and data extraction for engagement strategies was guided by a codebook. We used narrative synthesis to report on findings. RESULTS: In total, 150 collaborative care programs were analyzed. The synthesis showed that personalized care planning or shared decision making were practiced in fewer than half of programs. Practices related to personalized care planning, and to a lesser extent shared decision making, involved multiple members of the collaborative care team, with care managers playing a pivotal role in supporting patient and family engagement. Opportunities for quality improvement were identified, including fostering greater patient involvement in collaborative goal setting and integrating training and decision aids to promote shared decision making. CONCLUSION: This review suggests that personalized care planning and shared decision making could be more fully integrated within collaborative care programs for depression and anxiety disorders. Their absence in some programs is a missed opportunity to spread person-centered mental health practices in primary care.

Strategizing Research for Impact.

In its Strategic Plan 2021-2026, the Canadian Institutes of Health Research - Institute of Health Services and Policy Research (IHSPR) convincingly expresses its desire to expand capacity for applied health services and policy research (HSPR) and better mobilize research results for health system transformation geared toward the Quadruple Aim and health equity for all (CIHR IHSPR 2021). These strategic priorities echo views widely shared within the HSPR community, and we commend IHSPR for its leadership and vision. Recognizing the systemic challenges ahead of us, this commentary considers the HSPR community's capacity to achieve the promise of learning health systems, given the obstacles likely to hinder their rapid scale-up over the next five years. Next, we consider the spread of virtual care during the pandemic to illustrate the embedded and negotiated nature of innovation in health systems and the need for vigilance as to the social distribution of their benefits and costs. Finally, a critical review of the strategic plan provides insights into how research is governed in the HSPR field. Based on this analysis, it appears essential to reconsider health system transformation as social system transformation and strengthen interdisciplinary and comparative research. Looking forward, developing a science of science to better understand the conditions associated with high-impact research should be a cross-cutting priority for Canada's HSPR community.

For a structured response to the psychosocial consequences of the restrictive measures imposed by the global COVID-19 health pandemic: the MAVIPAN longitudinal prospective cohort study protocol.

INTRODUCTION: The COVID-19 pandemic and associated restrictive measures have caused important disruptions in economies and labour markets, changed the way we work and socialise, forced schools to close and healthcare and social services to reorganise. This unprecedented crisis forces individuals to make considerable efforts to adapt and will have psychological and social consequences, mainly on vulnerable individuals, that will remain once the pandemic is contained and will most likely exacerbate existing social and gender health inequalities. This crisis also puts a toll on the capacity of our healthcare and social services structures to provide timely and adequate care. The MAVIPAN (Ma vie et la pandémie/ My Life and the Pandemic) study aims to document how individuals, families, healthcare workers and health organisations are affected by the pandemic and how they adapt. METHODS AND ANALYSIS: MAVIPAN is a 5-year longitudinal prospective cohort study launched in April 2020 across the province of Quebec (Canada). Quantitative data will be collected through online questionnaires (4-6 times/year) according to the evolution of the pandemic. Qualitative data will be collected with individual and group interviews and will seek to deepen our understanding of coping strategies. Analysis will be conducted under a mixed-method umbrella, with both sequential and simultaneous analyses of quantitative and qualitative data. ETHICS AND DISSEMINATION: MAVIPAN aims to support the healthcare and social services system response by providing high-quality, real-time information needed to identify those who are most affected by the pandemic and by guiding public health authorities' decision making regarding intervention and resource allocation to mitigate these impacts. MAVIPAN was approved by the Ethics Committees of the Primary Care and Population Health Research Sector of CIUSSS de la Capitale-Nationale (Committee of record) and of the additional participating institutions. TRIAL REGISTRATION NUMBER: NCT04575571.

Effects of Telerehabilitation on Patient Adherence to a Rehabilitation Plan: Protocol for a Mixed Methods Trial.

BACKGROUND: Strong evidence supports beginning stroke rehabilitation as soon as the patient's medical status has stabilized and continuing following discharge from acute care. However, adherence to rehabilitation treatments over the rehabilitation phase has been shown to be suboptimal. OBJECTIVE: The aim of this study is to assess the impact of a telerehabilitation platform on stroke patients' adherence to a rehabilitation plan and on their level of reintegration into normal social activities, in comparison with usual care. The primary outcome is patient adherence to stroke rehabilitation (up to 12 weeks), which is hypothesized to influence reintegration into normal living. Secondary outcomes for patients include functional recovery and independence, depression, adverse events related to telerehabilitation, use of services (up to 6 months), perception of interprofessional shared decision making, and quality of services received. Interprofessional collaboration as well as quality of interprofessional shared decision making will be measured with clinicians. METHODS: In this interrupted time series with a convergent qualitative component, rehabilitation teams will be trained to develop rehabilitation treatment plans that engage the patient and family, while taking advantage of a telerehabilitation platform to deliver the treatment. The intervention will be comprised of 220 patients who will take part in stroke telerehabilitation with an interdisciplinary group of clinicians (telerehabilitation group) versus face-to-face standard of care (control group: n=110 patients). RESULTS: Our Research Ethics Board approved the study in June 2020. Data collection for the control group is underway, with another year planned before we begin the intervention phase. CONCLUSIONS: This study will contribute to the minimization of both knowledge and practice gaps, while producing robust, in-depth data on the factors related to the effectiveness of telerehabilitation in a stroke rehabilitation continuum. Findings will inform best practice guidelines regarding telecare services and the provision of telerehabilitation, including recommendations for effective interdisciplinary collaboration regarding stroke rehabilitation. TRIAL REGISTRATION: ClinicalTrials.gov NCT04440215; https://clinicaltrials.gov/ct2/show/NCT04440215. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/32134.

Inequities in the delivery of mental health care: a grounded theory study of the policy context of primary care.

BACKGROUND: Strengthening capacity for mental health in primary care improves health outcomes by providing timely access to coordinated and integrated mental health care. The successful integration of mental health in primary care is highly dependent on the foundation of the surrounding policy context. In Ontario, Canada, policy reforms in the early 2000's led to the implementation of a new interprofessional team-model of primary care called Family Health Teams. It is unclear the extent to which the policy context in Ontario influenced the integration of mental health care in Family Health Teams emerging from this period of policy reform. The research question guiding this study was: what were key features of Ontario's policy context that influenced FHTs capacity to provide mental health services for mood and anxiety disorders? METHODS: A qualitative study informed by constructivist grounded theory. Individual interviews were conducted with executive directors, family physicians, nurse practitioners, nurses, and the range of professionals who provide mental health services in interprofessional primary care teams; community mental health providers; and provincial policy and decision makers. We used an inductive approach to data analysis. The electronic data management programme NVivo11 helped organise the data analysis process. RESULTS: We conducted 96 interviews with 82 participants. With respect to the contextual factors considered to be important features of Ontario's policy context that influenced primary care teams' capacity to provide mental health services, we identified four key themes: i) lack of strategic direction for mental health, ii) inadequate resourcing for mental health care, iii) rivalry and envy, and, iv) variations across primary care models. CONCLUSIONS: As the first point of contact for individuals experiencing mental health difficulties, primary care plays an important role in addressing population mental health care needs. In Ontario, the successful integration of mental health in primary care has been hindered by the lack of strategic direction, and inconsistent resourcing for mental health care. Achieving health equity may be stunted by the structural variations for mental health care across Family Health Teams and across primary care models in Ontario.

Theory-based approach to developing an implementation plan to support the adoption of a patient decision aid for Down syndrome prenatal screening.

BACKGROUND: Our team has developed a decision aid to help pregnant women and their partners make informed decisions about Down syndrome prenatal screening. However, the decision aid is not yet widely available in Quebec's prenatal care pathways. OBJECTIVE: We sought to identify knowledge translation strategies and develop an implementation plan to promote the use of the decision aid in prenatal care services in Quebec, Canada. METHODS: Guided by the Knowledge-to-Action Framework and the Theoretical Domains Framework, we performed a synthesis of our research (11 publications) on prenatal screening in Quebec and on the decision aid. Two authors independently reviewed the 11 articles, extracted information, and mapped it onto the Knowledge-to-Action framework. Using participatory action research methods, we then recruited pregnant women, health professionals, managers of three prenatal care services, and researchers to (a) identify the different clinical pathways followed by pregnant women and (b) select knowledge translation strategies for a clinical implementation plan. Then, based on all the information gathered, the authors established a consensus on strategies to include in the plan. RESULTS: Our knowledge synthesis showed that pregnant women and their partners are not sufficiently involved in the decision-making process about prenatal screening and that there are numerous barriers and facilitators of the use of the decision aid in clinical practice (e.g., low intention to use it among health providers). Using a participatory action approach, we met with five pregnant women, three managers, and six health professionals. They informed us about three of Quebec's prenatal care pathways and helped us identify 20 knowledge translation strategies (e.g., nurse discusses decision aid with women before they meet the doctor) to include in a clinical implementation plan. The research team reached a consensus about the clinical plan and also about broader organizational strategies, such as training healthcare providers in the use of the decision aid, monitoring its impact (e.g., measure decisional conflict) and sustaining its use (e.g., engage key stakeholders in the implementation process). CONCLUSION: Next steps are to pilot our implementation plan while further identifying global strategies that target institutional, policy, and systemic supports for implementation.

Patient perspectives on quality of care for depression and anxiety in primary health care teams: A qualitative study.

BACKGROUND: Widespread policy reforms in Canada, the United States and elsewhere over the last two decades strengthened team models of primary care by bringing together family physicians and nurse practitioners with a range of mental health and other interdisciplinary providers. Understanding how patients with depression and anxiety experience newer team-based models of care delivery is essential to explore whether the intended impact of these reforms is achieved, identify gaps that remain and provide direction on strengthening the quality of mental health care. OBJECTIVE: The main study objective was to understand patients' perspectives on the quality of care that they received for anxiety and depression in primary care teams. METHODS: This was a qualitative study, informed by constructivist grounded theory. We conducted focus groups and individual interviews with primary care patients about their experiences with mental health care. Focus groups and individual interviews were recorded and transcribed verbatim. Grounded theory guided an inductive analysis of the data. RESULTS: Forty patients participated in the study: 31 participated in one of four focus groups, and nine completed an individual interview. Participants in our study described their experiences with mental health care across four themes: accessibility, technical care, trusting relationships and meeting diverse needs. CONCLUSION: Greater attention by policymakers is needed to strengthen integrated collaborative practices in primary care so that patients have similar access to mental health services across different primary care practices, and smoother continuity of care across sectors. The research team is comprised of individuals with lived experience of mental health who have participated in all aspects of the research process.

Nurturing a culture of curiosity in family medicine and primary care: The Section of Researchers' Blueprint 2 (2018-2023).

OBJECTIVE: To describe Blueprint 2 (2018-2023), the 5-year strategic plan launched in 2018 by the Section of Researchers (SOR), as well as its guiding principles and the process used to develop it. COMPOSITION OF THE COMMITTEE: Blueprint 2 was co-created by many stakeholders from across Canada and led by the SOR Council (SORC). The process started with an external, commissioned program evaluation in 2017 of the effect of the first SOR Blueprint (2012-2017). The findings and recommendations arising from the evaluation were presented in a day-long facilitated invitational retreat, hosted by the SORC in September 2017 and involving 40 key stakeholders. METHODS: Blueprint 2 was created using a multi-pronged, participatory, and iterative process to ensure broad input and alignment with current and future opportunities and priorities. REPORT: Blueprint 2 incorporates 4 strategic priority areas, each supported by objectives and actions. The strategic priority areas are membership, capacity building, advocacy, and partnerships. This updated Blueprint provides a useful, membership-driven strategic plan specifically for the SOR. The implementation of its objectives will promote research and quality improvement and contribute to building a culture of curiosity. Blueprint 2 emphasizes research and quality improvement that emanate from the realities of everyday practice and are rooted in everyday work. At its core are patient- and community-oriented approaches; it also contributes to achieving the Quadruple Aim. These outcomes will further the integration of the scholar role into daily practice for family physicians and primary care clinicians and teams. CONCLUSION: The ability of family physicians to identify, study, and cite their own evidence is essential to establishing the value and effect of primary care, including family medicine, in relation to Canadians' health and the Canadian health care system.

Understanding the positive outcomes of discharge planning interventions for older adults hospitalized following a fall: a realist synthesis.

BACKGROUND: Older adults hospitalized following a fall often encounter preventable adverse events when transitioning from hospital to home. Discharge planning interventions developed to prevent these events do not all produce the expected effects to the same extent. This realist synthesis aimed to better understand when, where, for whom, why and how the components of these interventions produce positive outcomes. METHODS: Nine indexed databases were searched to identify scientific papers and grey literature on discharge planning interventions for older adults (65+) hospitalized following a fall. Manual searches were also conducted. Documents were selected based on relevance and rigor. Two reviewers extracted and compiled data regarding intervention components, contextual factors, underlying mechanisms and positive outcomes. Preliminary theories were then formulated based on an iterative synthesis process. RESULTS: Twenty-one documents were included in the synthesis. Four Intervention-Context-Mechanism-Outcome configurations were developed as preliminary theories, based on the following intervention components: 1) Increase two-way communication between healthcare providers and patients/caregivers using a family-centered approach; 2) Foster interprofessional communication within and across healthcare settings through both standardized and unofficial information exchange; 3) Provide patients/caregivers with individually tailored fall prevention education; and 4) Designate a coordinator to manage discharge planning. These components should be implemented from patient admission to return home and be supported at the organizational level (contexts) to trigger knowledge, understanding and trust of patients/caregivers, adjusted expectations, reduced family stress, and sustained engagement of families and professionals (mechanisms). These optimal conditions improve patient satisfaction, recovery, functional status and continuity of care, and reduce hospital readmissions and fall risk (outcomes). CONCLUSIONS: Since transitions are critical points with potential communication gaps, coordinated interventions are vital to support a safe return home for older adults hospitalized following a fall. Considering the organizational challenges, simple tools such as pictograms and drawings, combined with computer-based communication channels, may optimize discharge interventions based on frail patients' needs, habits and values. Empirically testing our preliminary theories will help to develop effective interventions throughout the continuum of transitional care to enhance patients' health and reduce the economic burden of avoidable care.

Evaluating implementation and impact of a provincial quality improvement collaborative for the management of chronic diseases in primary care: the COMPAS+ study protocol.

BACKGROUND: Chronic conditions such as diabetes and chronic obstructive pulmonary disease (COPD) are common and burdensome diseases primarily managed in primary care. Yet, evidence points to suboptimal quality of care for these conditions in primary care settings. Quality improvement collaboratives (QICs) are organized, multifaceted interventions that can be effective in improving chronic disease care processes and outcomes. In Quebec, Canada, the Institut national d'excellence en santé et en services sociaux (INESSS) has developed a large-scale QIC province-wide program called COMPAS+ that aims to improve the prevention and management of chronic diseases in primary care. This paper describes the protocol for our study, which aims to evaluate implementation and impact of COMPAS+ QICs on the prevention and management of targeted chronic diseases like diabetes and COPD. METHODS: This is a mixed-methods, integrated knowledge translation study. The quantitative component involves a controlled interrupted time series involving nine large integrated health centres in the province. Study sites will receive one of two interventions: the multifaceted COMPAS+ intervention (experimental condition) or a feedback only intervention (control condition). For the qualitative component, a multiple case study approach will be used to achieve an in-depth understanding of individual, team, organizational and contextual factors influencing implementation and effectiveness of the COMPAS+ QICs. DISCUSSION: COMPAS+ is a QI program that is unique in Canada due to its integration within the governance of the Quebec healthcare system and its capacity to reach many primary care providers and people living with chronic diseases across the province. We anticipate that this study will address several important gaps in knowledge related to large-scale QIC projects and generate strong and useful evidence (e.g., on leadership, organizational capacity, patient involvement, and implementation) having the potential to influence the design and optimisation of future QICs in Canada and internationally.

Enhancing interprofessionalism in shared decision-making training within homecare settings: a short report.

Training in shared decision-making (SDM) often focuses solely on dyadic relationships between one healthcare provider and one patient. However, many healthcare decisions often involve two or more health professionals. These decisions warrant utilizing an interprofessional shared decision-making (IP-SDM) approach which enables patients and their caregivers to face difficult decisions around care together. Most existing SDM training programs fall short when building interprofessional (IP) competencies and require an approach that integrates IP with SDM. This short report discusses the creation and trial implementation of three enhanced education tools (a video, role-play exercise with decision aid, and an IP observation aid) for an IP-SDM workshop focused on helping homecare teams collaborate with seniors and their caregivers throughout the decision-making process. We developed and implemented these tools in eight study sites of a larger randomized control trial to test the training workshop for homecare teams. The workshop and tools helped participants overcome interprofessional challenges in their work. Participants evaluated the tools and workshop, which offered guidance to better translate teachable IP collaboration competencies within SDM.

Strategies for engaging patients and families in collaborative care programs for depression and anxiety disorders: A systematic review.

BACKGROUND: Patients and families are often referred to as important partners in collaborative mental health care (CMHC). However, how to meaningfully engage them as partners remains unclear. We aimed to identify strategies for engaging patients and families in CMHC programs for depression and anxiety disorders. METHODS: We updated a Cochrane review of CMHC programs for depression and anxiety disorders. Searches were conducted in Cochrane CCDAN and CINAHL, complemented by additional database searches, trial registry searches, and cluster searches for 'sibling' articles. Coding and data extraction of engagement strategies was an iterative process guided by a conceptual framework. We used narrative synthesis and descriptive statistics to report on findings. FINDINGS: We found 148 unique CMCH programs, described in 578 articles. Most programs (96%) featured at least one strategy for engaging patients or families. Programs adopted 15 different strategies overall, with a median of two strategies per program (range 0-9 strategies). The most common strategies were patient education (87% of programs) and self-management supports (47% of programs). Personalized care planning, shared decision making, and family or peer supports were identified in fewer than one third of programs. LIMITATIONS: Our search strategy was designed to capture programs evaluated in clinical trials and so other innovative programs not studied in trials were likely missed. CONCLUSION: Most CMHC programs for depression and anxiety disorders adopted a limited number of strategies to engage patients and families in their care. However, this review identifies numerous strategies that can be used to strengthen the patient- and family-centeredness of collaborative care.

The pitfalls of scaling up evidence-based interventions in health.

Policy-makers worldwide are increasingly interested in scaling up evidence-based interventions (EBIs) to larger populations, and implementation scientists are developing frameworks and methodologies for achieving this. But scaling-up does not always produce the desired results. Why not? We aimed to enhance awareness of the various pitfalls to be anticipated when planning scale-up. In lower- and middle-income countries (LMICs), the scale-up of health programs to prevent or respond to outbreaks of communicable diseases has been occurring for many decades. In high-income countries, there is new interest in the scaling up of interventions that address communicable and non-communicable diseases alike. We scanned the literature worldwide on problems encountered when implementing scale-up plans revealed a number of potential pitfalls that we discuss in this paper. We identified and discussed the following six major pitfalls of scaling-up EBIs: 1) the cost-effectiveness estimation pitfall, i.e. accurate cost-effectiveness estimates about real-world implementation are almost impossible, making predictions of economies of scale unreliable; 2) the health inequities pitfall, i.e. some people will necessarily be left out and therefore not benefit from the scaled-up EBIs; 3) the scaled-up harm pitfall, i.e. the harms as well as the benefits may be amplified by the scaling-up; 4) the ethical pitfall, i.e. informed consent may be a challenge on a grander scale; 5) the top-down pitfall, i.e. the needs, preferences and culture of end-users may be forgotten when scale-up is directed from above; and 6) the contextual pitfall, i.e. it may not be possible to adapt the EBIs to every context. If its pitfalls are addressed head on, scaling-up may be a powerful process for translating research data into practical improvements in healthcare in both LMICs and high-income countries, ensuring that more people benefit from EBIs.

A framework for value-creating learning health systems.

BACKGROUND: Interest in value-based healthcare, generally defined as providing better care at lower cost, has grown worldwide, and learning health systems (LHSs) have been proposed as a key strategy for improving value in healthcare. LHSs are emerging around the world and aim to leverage advancements in science, technology and practice to improve health system performance at lower cost. However, there remains much uncertainty around the implementation of LHSs and the distinctive features of these systems. This paper presents a conceptual framework that has been developed in Canada to support the implementation of value-creating LHSs. METHODS: The framework was developed by an interdisciplinary team at the Institut national d'excellence en santé et en services sociaux (INESSS). It was informed by a scoping review of the scientific and grey literature on LHSs, regular team discussions over a 14-month period, and consultations with Canadian and international experts. RESULTS: The framework describes four elements that characterise LHSs, namely (1) core values, (2) pillars and accelerators, (3) processes and (4) outcomes. LHSs embody certain core values, including an emphasis on participatory leadership, inclusiveness, scientific rigour and person-centredness. In addition, values such as equity and solidarity should also guide LHSs and are particularly relevant in countries like Canada. LHS pillars are the infrastructure and resources supporting the LHS, whereas accelerators are those specific structures that enable more rapid learning and improvement. For LHSs to create value, such infrastructures must not only exist within the ecosystem but also be connected and aligned with the LHSs' strategic goals. These pillars support the execution, routinisation and acceleration of learning cycles, which are the fundamental processes of LHSs. The main outcome sought by executing learning cycles is the creation of value, which we define as the striking of a more optimal balance of impacts on patient and provider experience, population health and health system costs. CONCLUSIONS: Our framework illustrates how the distinctive structures, processes and outcomes of LHSs tie together with the aim of optimising health system performance and delivering greater value in health systems.

Decisional Conflict Scale Use over 20 Years: The Anniversary Review.

Background. The Decisional Conflict Scale (DCS) measures 5 dimensions of decision making (feeling: uncertain, uninformed, unclear about values, unsupported; ineffective decision making). We examined the use of the DCS over its initial 20 years (1995 to 2015). Methods. We conducted a scoping review with backward citation search in Google Analytics/Web of Science/PubMed, followed by keyword searches in Cochrane Library, PubMed, Ovid MEDLINE, EMBASE, CINAHL, AMED, PsycINFO, PRO-Quest, and Web of Science. Eligible studies were published between 1995 and March 2015, used an original experimental/observational research design, concerned a health-related decision, and provided DCS data (total/subscales). Author dyads independently screened titles, abstracts, full texts, and extracted data. We performed narrative data synthesis. Results. We included 394 articles. DCS use appeared to increase over time. Three hundred nine studies (76%) used the original DCS, and 29 (7%) used subscales only. Most studies used the DCS to evaluate the impact of decision support interventions (n = 238, 59%). The DCS was translated into 13 languages. Most decisions were made by people for themselves (n = 353, 87%), about treatment (n = 225, 55%), or testing (n = 91, 23%). The most common decision contexts were oncology (n = 113, 28%) and primary care (n = 82, 20%). Conclusions. This is the first study to descriptively synthesize characteristics of DCS data. Use of the DCS as an outcome measure for health decision interventions has increased over its 20-year existence, demonstrating its relevance as a decision-making evaluation measure. Most studies failed to report when decisional conflict was measured during the decision-making process, making scores difficult to interpret. Findings from this study will be used to update the DCS user manual.